Prognostic factors and treatment outcome in childhood Hodgkin disease

Clinicopathologic features and therapy outcome in childhood Hodgkin's lymphoma: a report from tertiary care center in Saudi Arabia

BACKGROUND

Hodgkin lymphoma (HL) is lymphoid neoplasm usually affecting lymphatic system; it accounts 3.6% of cancers in Saudi Arabia. Modern treatment protocols had shown particular success rates in overall-survival (OS) and event-free-survival (EFS). In our study, we reviewed the medical records of 80 pediatric and young adolescent patients diagnosed HL from January 2006 to July 2020, treated at tertiary care hospital in Riyadh, Saudi Arabia. Demographic, clinical, and pathological data were explored. First line therapy was ABVD, COG, COPP, R-CHOP, or radiotherapy alone in 53/80 (66.4%), 24/80 (30%), 1/80 (1.2%), 1/80 (1.2%), or 1/80 (1.2%) patients; respectively. Response assessment was done by CT + / - PET scan after first 2 cycles then every 2 cycle and end of therapy. Another assessment was done if any clinical suspicion of recurrence.

RESULTS

Median age 11 (range 3-16) years. Males to females 1.3:1. Seventy-two out of eighty (90%) patients showed first complete remission (CR1) and maintained remission for median 40 (range 7-136) months. Eight out of eighty (10%) patients showed refractory disease. Nineteen patients received salvage therapy (ICE or ESHAP/brentuximab vedotin or gemcitabine/brentuximab vedotin), 14/19 (73.7%) had 2nd complete remission (CR2) for median time 24 (ranged 9-78) months, while 5/19 (26.3%) did not show any response. Five-year OS and EFS were 95% and 75%. Two patients had 2ry malignant neoplasms, one had AML and died, the other had malignant fibrous histocytoma and still alive. None of our patients had fertility problem. Also, they did not experience chronic pulmonary or cardiotoxicity. Classic Hodgkin's lymphoma: nodular sclerosis subtype was more prominent (55%) than mixed cellularity subtype (22.5%), which is similar to several European and US studies, lymphocyte rich (11.25%) and lymphocyte depleted (0%), while nodular lymphocyte predominant Hodgkin's lymphoma (11.25%).

CONCLUSIONS

Our study provided unique descriptive study of childhood HL, in Saudi Arabia, with valuable insight into the long-term outcome and late toxicity. Our results are comparable to other studies in the Middle East and European countries.

3' untranslated region A>C (rs3212227) polymorphism of Interleukin 12B gene as a potential risk factor for Hodgkin's lymphoma in Brazilian children and adolescents

Interleukin 12 plays an important role in immunoregulation between the T helper 1/T helper 2 lymphocytes and in the antiviral and antitumor immune response. The aim of this study was to investigate the possible association between the interleukin 12B polymorphism rs3212227 and the risk to develop Hodgkin's lymphoma in childhood and adolescents. A total of 100 patients with Hodgkin's lymphoma and a group of 181 healthy controls were selected at random from a forensic laboratory of the University of Pernambuco. The AA genotype was detected in the controls (53.04%) and the AC genotype was found in the patients (54%). The AC genotype showed an association with the development of Hodgkin's lymphoma (odds ratio = 2.091, 95% confidence interval = 1.240-3.523, p = 0.007). When AC + CC genotypes were analyzed together, an increase in risk of 1.9 times more chances for HL development could be observed (odds ratio = 1.923, 95% confidence interval = 1.166-3.170, p = 0.014). However, there was no association between the AC and CC genotypes of the interleukin 12B polymorphism with the clinical risk group (p = 0.992, p = 0.648, respectively). Our results suggest that the presence of the C allele may be contributing to the development of Hodgkin's lymphoma in children and adolescents.

Flow cytometry for assessment of the tumor microenvironment in pediatric Hodgkin lymphoma

BACKGROUND

The role of flow cytometry in diagnosis and management of Hodgkin lymphoma (HL) remains limited. As knowledge emerges of the tumor microenvironment in this disease, various methods are being evaluated in its study. This study examines the microenvironment using flow cytometry to assess differences between subtypes and clinicopathologic correlates.

PROCEDURE

A retrospective cross-sectional study was performed analyzing the tumor immunophenotype, by flow cytometry, for 31 children with classical HL. Correlation was made with patient information, including outcome.

RESULTS

The makeup of the tumor microenvironment varies across subtype of HL, with T cells predominating in nodular sclerosis (NS), and similar proportions of B and T cells in mixed cellularity (MC). CD4 cells predominate in NS, whereas CD8 more so in MC subtype. The rate of continuous complete remission is significantly higher in the MC subgroup. Last, the proportion of HLA-DR/CD38 copositive lymphocytes was an independent prognostic factor for relapse/refractoriness.

CONCLUSIONS

This study indicates that flow cytometry can be used to examine the tumor microenvironment in HL and that percentage of HLA-DR/CD38 copositive lymphocytes may be a biomarker for relapse and refractoriness in pediatric HL.

Childhood Hodgkin International Prognostic Score (CHIPS) Predicts event-free survival in Hodgkin Lymphoma: A Report from the Children's Oncology Group

BACKGROUND

Early response to initial chemotherapy in Hodgkin lymphoma (HL) measured by computed tomography (CT) and/or positron emission tomography (PET) after two to three cycles of chemotherapy may inform therapeutic decisions. Risk stratification at diagnosis could, however, allow earlier and potentially more efficacious treatment modifications.

PATIENTS AND METHODS

We developed a predictive model for event-free survival (EFS) in pediatric/adolescent HL using clinical data known at diagnosis from 1103 intermediate-risk HL patients treated on Children's Oncology Group protocol AHOD0031 with doxorubicin, bleomycin, vincristine, etoposide, prednisone, cyclophosphamide (ABVE-PC) chemotherapy and radiation. Independent predictors of EFS were identified and used to develop and validate a prognostic score (Childhood Hodgkin International Prognostic Score [CHIPS]). A training cohort was randomly selected to include approximately half of the overall cohort, with the remainder forming the validation cohort.

RESULTS

Stage 4 disease, large mediastinal mass, albumin (<3.5), and fever were independent predictors of EFS that were each assigned one point in the CHIPS.  Four-year EFS was 93.1% for patients with CHIPS = 0, 88.5% for patients with CHIPS = 1, 77.6% for patients with CHIPS = 2, and 69.2% for patients with CHIPS = 3.

CONCLUSIONS

CHIPS was highly predictive of EFS, identifying a subset (with CHIPS 2 or 3) that comprises 27% of intermediate-risk patients who have a 4-year EFS of <80% and who may benefit from early therapeutic augmentation.  Furthermore, CHIPS identified higher risk patients who were not identified by early PET or CT response. CHIPS is a robust and inexpensive approach to predicting risk in patients with intermediate-risk HL that may improve ability to tailor therapy to risk factors known at diagnosis.

ABVD-Based Therapy for Hodgkin Lymphoma in Children and Adolescents: Lessons Learnt in a Tertiary Care Oncology Center in a Developing Country

BACKGROUND

As Hodgkin lymphoma (HL) is a highly curable malignancy, most current pediatric trials focus on strategies aimed at reducing late effects of therapy. We report our results with doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) therapy.

PROCEDURE

We retrospectively analyzed 17 years (1996-2013) data of patients ≤18 years of age with HL. All patients received ABVD chemotherapy and involved field radiotherapy (IFRT) was reserved for those with bulky disease or partial response. The analysis was carried out to assess overall survival (OS) and freedom from treatment failure (FFTF) and factors predicting the events.

RESULTS

Of 167 eligible patients, 72 (43.1%) had B symptoms, 28 (16.7%) had bulky disease, 31 (18.6%) had >4 lymph node regions, and 53 (31.8%) had advanced disease (stages III and IV). In all, 87% patients received six cycles of ABVD and IFRT was administered to 51 (30.5%) patients. The 5-year OS and FFTF were 95.9% and 79%, respectively, and were similar in patients treated with or without IFRT. On multivariable analysis, advanced disease (stages III and IV), involvement of >4 lymph node regions, and serum lactate dehydrogenase (LDH) ≥500 IU/l at diagnosis were statistically significant factors for FFTF (P = 0.03, 0.003, 0.048, respectively).

CONCLUSIONS

The excellent survival of HL patients in the setting of a developing country reported in this retrospective analysis warrants treatment reduction, especially for early-stage patients. The use of risk- and response-based stratification incorporating disease stage, involved lymph node regions, and serum LDH, along with fluorodeoxyglucose-positron emission tomography-based response, may guide development of effective and less toxic protocols.

Hodgkin lymphoma in childhood: clinicopathological features and therapy outcome at 2 centers from a developing country

Hodgkin lymphoma (HL) accounts for 5% to 6% of all childhood cancer. It displays characteristic epidemiological, clinical, and pathological features according to various geographic areas. We aimed to assess the epidemiological aspects, clinicopathological features, and treatment outcome of pediatric HL treated at 2 Egyptian centers: Zagazig University Pediatric Oncology Unit and Benha Special Hospital Pediatric Oncology Unit. We carried a cross-sectional retrospective study by reviewing medical records for all patients admitted with the diagnosis of HL over 8 years in 2 oncology units during the period from January 2004 to January 2012. Age of the patients at presentation ranged from 3 to 14 years (median 6 years) and male: female ratio 1.7:1. Lymphadenopathy was the most common presentation (96.6%). Mixed cellularity subtype was dominant (50.8%), followed by nodular sclerosis (28.9%), lymphocyte-rich (18.6%) with lymphocyte depletion being the least dominant (1.7%). More than half of patients (55.9 %) had advanced disease (Ann Arbor stage III/IV disease). The duration of follow-up ranged from 5 to 87 months (mean 39.8 ± 24.1 months). The 5-year overall survival and event-free survival for patients were 96.6% and 84.7% respectively. In Egypt, HL occurs in young age group, with a higher incidence of mixed cellularity subtype and advanced disease. None of the clinical, epidemiological, or pathological characteristics had a significant association with the overall survival. The outcomes of HL in our 2 centers were satisfactory approaching the international percentage.

Thyroid functions in long-term survivors of pediatric Hodgkin's lymphoma treated with chemotherapy and radiotherapy

OBJECTIVE

Post-treatment endocrine disturbances are common in cancer patients who have received radiotherapy or chemotherapy. The objective of this study was to evaluate the thyroid functions of long-term survivors of pediatric Hodgkin's lymphoma treated with chemotherapy and radiotherapy.

METHODS

Thyroid functions of 55 Hodgkin's lymphoma patients (M/F:2.05/1) in complete remission were evaluated retrospectively.

RESULTS

The mean age of the patients at diagnosis was 10.35±4.09 (range: 2.83-17) years and the mean follow-up period was 5.54±3.68 (range: 0.92-13.92) years. All patients received chemotherapy; a total of 50 patients (90.9%) underwent radiotherapy, 42 (76.4%) of whom received neck/mantle radiotherapy. Thyroid function tests were abnormal in 14 (24.5%) patients and normal - in the remaining 41 (74.5%). A diagnosis of subclinical and overt hypothyroidism was made in 11 (78.6%) and 3 (21.4%) patients with abnormal thyroid function tests, respectively. Nearly one-fourth (21.4%) of all thyroid function disorders were detected in the first year of follow-up. A statistically significant correlation was found between the dose of mantle radiotherapy and thyroid function disorder (p=0.002). In addition, statistically significant correlations were established between thyroid examination or thyroid ultrasonography findings and thyroid functions (p <0.001 or p=0.006, respectively).

CONCLUSIONS

Radiation-induced thyroid disorders may develop in pediatric Hodgkin's lymphoma patients in complete remission starting as early as the first year after treatment and are dose-dependent. Patients, particularly those who have been exposed to radiotherapy of the neck, must be followed up closely for occurrence of thyroid dysfunctions.

The treatment of childhood Hodgkin lymphoma: improved survival in a developing country

BACKGROUND

To evaluate the clinical characteristics, treatment regimens, and outcome of children with Hodgkin lymphoma in a developing country over a period of 34 years.

METHODS

This paper retrospectively evaluates the treatment and prognosis of 614 children with Hodgkin lymphoma disease between 1971 and 2005. All patients were treated with chemotherapy, and also received radiotherapy.

RESULTS

There were 452 males and 162 females with a median age of 8 years (2 to 21); 183 patients had B symptoms. There were 165, 185, 145, and 119 patients in stage I, II, III, and IV, respectively. Histopathologic subtypes were mixed cellularity (344 patients), nodular sclerosis (90), lymphocytic predominance (62), lymphocytic depletion (46), unclassified types (69), and nodular lymphocyte predominant Hodgkin lymphoma (3). Overall (OS) and event-free survival (EFS) rates were 83 and 60%, though OS rates varied according to chemotherapy protocol; age; presence of B symptoms, leukocytosis, anemia, and extranodal involvement; and stage at diagnosis. Over the years, the median age of patients increased, as did the frequency of the nodular sclerosing type of disease.

CONCLUSIONS

This is one of the largest series in a single center. The increase in the median age and in the frequency of the nodular-sclerosing type are thought to be related to the development status of Turkey. The ABVD protocol yielded the best survival rates and should be used for treatment of patients with Hodgkin lymphoma.

Clinical characteristics and outcome of pediatric patients with stage IV Hodgkin lymphoma

BACKGROUND AND OBJECTIVES:

While treatment outcomes for patients with Hodgkin lymphoma (HL) have improved remarkably, patients with disseminated disease still have a poorer outcome. stage IV HL is often reported with other ‘advanced stage’ categories, confusing the specific contribution of disease dissemination to the outcome. This single-institution report looks at characteristics and outcomes of this specific category.

PATIENTS AND METHODS:

The medical records of pediatric HL patients (<14 years) from 1975 through 2003 were retrospectively reviewed and the data analyzed.

RESULTS:

Stage IV patients (n=67) had more poor-risk characteristics than patients in stages I-III (n=300) (B symptoms 86.6% vs. 19.3%, bulky disease 57.6% vs. 45.5% and mediastinal mass 77.6% vs. 29.7%; P<.001 for all characteristics). The liver was the most common extralymphatic site (in 51.5% of patients with stage IV disease. Stage IV patients received chemotherapy (CT) alone (n=55) or combined modality therapy (CMT) (n=12). Fifty-four patients (80.6%) achieved complete remission, 2 (3%) partial remission, 10 (14.9%) had progressive disease and 1 was lost to follow up. Overall survival was 79.4% and event-free survival (EFS) was 63.9% at 5 years. There was a non-significant benefit for CMT (OS=91.7% v. 77.1%, P=.3; EFS=70.7% v. 62.7%, p=.3). Ten of 12 relapsed and only 1 of 10 progressive disease patients were salvaged. On multivariate analysis, failure to achieve complete remission with CT was associated with a poorer outcome.

CONCLUSION:

Stage IV disease is associated with poor risk features and confers a worse outcome than stage I-III disease. Achievement of complete remission with CT is an important prognostic feature. Slow responders may require novel and/or aggressive therapy to achieve complete remission.

Developing anticancer chemotherapy services in a developing country: Hodgkin lymphoma experience

BACKGROUND AND OBJECTIVE

Reporting on how the cancer treatment facilities were developed at a medical college hospital in India and the profile and outcome of patients with Hodgkin lymphoma (HL) at this new center were the objectives of the study.

METHODS

Patients under 18 years with a diagnosis of HL were evaluated using abdominal ultrasonography, CT scan examination of chest, abdomen and pelvis and bone marrow examination. Most patients were treated with combination chemotherapy. Departments of Radiodiagnosis and Pathology were involved for evaluation. Radiotherapy when required was made available at a nearby hospital.

RESULTS

Thirty-five patients between 1.2 and 18 years (median age 7 years) were diagnosed as HL during the study period. Advanced disease (Stage IIb or more) was present in 83% cases. Mixed cellularity was the commonest histological subtype (50.5%). Primary therapy used was COPP in 29 (83%) cases. Of the 34 patients who received treatment 30 showed initial good response to therapy. One patient responded to ABVD after having progression on COPP. Of 31 responders, 4 relapsed. Twenty-seven patients (80%) are surviving free of disease for a median follow up of 4.5 years (range 1.5-18 years). Chemotherapy was well tolerated. Febrile neutropenia occurred in four cases.

CONCLUSIONS

Pediatric HL in India was characterized by advanced disease at presentation. Mixed-cellularity was the predominant histological subtype. An effective program was developed with initial attention to patients with HL.

Clinical and laboratorial prediction of bone marrow involvement in children and adolescents with Hodgkin Lymphoma

BACKGROUND

A risk group (RG) system to predict bone marrow involvement (BMI) based on clinical and laboratory parameters was previously shown to have prognostic value in adult patients with Hodgkin lymphoma (HL). Our aim was to test the applicability of BMI RG in an independent group of childhood and adolescent HL patients.

PROCEDURE

Seventy-eight HL patients (range 3-18, median 14 years old) were retrospectively studied, including revision of histopathological diagnosis and bilateral BM biopsies. Patients were divided into BMI high-, standard- and low-RG.

RESULTS

The high-RG included 29.5% of the patients, the standard-RG, 32%, and the low-RG, 38.5%. All the patients in the high-RG had stage III or IV. The five children (6.4%) with BMI were included in the high-RG (P = 0.001, chi(2) test) and had stage IV (P < 0.00001, chi(2) test). The BMI risk group out-performed the clinico-pathologic risk assessment in predicting BMI, showing 100% sensitivity, 75% specificity and a positive predictive value of 0.88. Neither BMI nor risk of BMI was statistically associated to age groups (</=14 years old or >14 years old), suggesting that age is not a risk factor for BMI in the pediatric population.

CONCLUSIONS

The application of BMI RG score was able to efficiently foresee BMI in a pediatric group of HL patients, adding independent information to clinico-pathologic BMI risk assessment.

Impact of concomitant thoracic interventions on feasibility of Nuss procedure

BACKGROUND

This study aimed to analyze the feasibility of subsequent minimally invasive pectus repair, particularly modified Nuss procedure, combined with simultaneous thoracic procedures for different underlying intrathoracic diseases and conditions.

METHODS

A total of 110 patients, who underwent minimally invasive pectus repair in Nuss technique over a 5-year period, were retrospectively analyzed concerning complications, cosmetic results, and satisfaction. Six patients (5%) underwent the Nuss procedure with concomitant thoracic interventions. Patients with prior cardiac surgery or planned redo pectus repair were not examined and were excluded. The mean age of 6 patients (3 male and 3 female) was 11 years (range, 5.5-17.2). Two patients with former left-sided transabdominal diaphragmatic hernia repair and 1 with former lobectomy of the left lower lobe underwent thoracoscopic adhesiolysis. Two underwent thoracotomy: one for closure of a recurrent left-sided diaphragmatic hernia with fundoplication owing to a large hiatal hernia, another for lobectomy of the right middle lobe owing to recurrent infections and bronchodysplasia. One patient presented with anterior mediastinal mass, which was suspected to be benign, and underwent thoracoscopic complete resection. All patients underwent a 1-stage procedure with subsequent simultaneous Nuss procedure.

RESULTS

Simultaneous Nuss procedure was feasible without intraoperative complications in all patients (100%). Thoracoscopic adhesiolysis did not affect the feasibility of the Nuss procedure in 3 patients with former diaphragmatic hernia repair, particularly former lobectomy in one. Thoracotomy with middle-lobe lobectomy, as well as repair of recurrent diaphragmatic hernia and fundoplication in 2, did not affect modified Nuss technique and dispensed thoracoscopic guidance. Histopathologic analysis in one patient with a removed anterior mediastinal mass revealed Hodgkin lymphoma (stage IA), and the patient received multiagent chemotherapy. The postoperative course was uneventful in 5 of 6 patients. One patient required intermittent drainage of pleural effusion after simultaneous lobectomy. At follow-up (6 months-5 years), 6 patients had excellent cosmetic results and good quality of life confirmed by a questionnaire. There was no evidence of recurrent malignancy in one patient after 6 months.

CONCLUSIONS

Thoracic surgery and subsequent Nuss procedure can be performed simultaneously. Underlying conditions, such as prior repair of congenital diaphragmatic hernia or diaphragmatic eventration, as well as former lobectomy, had no impact on feasibility. Open thoracotomy can be combined with Nuss procedure dispensing thoracoscopy.

Maladie de Hodgkin de l'enfant dans le sud tunisien: étude de 23 cas

PURPOSE

To discuss, through a retrospective study, the epidemiologic and anatomo-clinic aspects of paediatric Hodgkin disease (HD) in south Tunisia and to study the faisability of the French protocol MDH 90 for our patients.

PATIENTS AND METHODS

Between January 1995 and December 2000, we treated 23 children with HD. Initial work-up included clinical examination, radiological explorations (chest X ray, abdomen ultrasonography and computed tomography scan of chest, abdomen and pelvis), biological explorations (full blood count, erythrocyte sedimentation rate, serum albumin, liver functions tests) and a bone marrow biopsy. Treatment was inspired from the SFOP MDH 90 protocol. Overall survivals and disease free survivals were estimated with Kaplan-Meier method and compared with the log-rank test.

RESULTS

Mean age was 8.6 years (4-14 years), sex-ratio was 3.6. Histological subtypes 2 and 3 had the same frequency. Localised stages (I-II) were as frequent as advanced stages (III-IV). At the end of the treatment, the 18 evaluables patients were in complete remission. The 5-year overall survival (OS) and disease free survival (DFS) were 82 and 76% respectively. Localised stages and advanced stages had the same 5-year overall survival (82%). There were no statistical differences in term of OS between the different prognosis factors studied.

CONCLUSIONS

The particularity of our study was the identical frequency of the two histological subtypes 2 and 3 and of localised and advanced stages. The MDH 90 protocol is feasable for our patients with satisfactory results similar to those found in the literature.

Outcome of a risk-related therapeutic strategy used prospectively in a population-based study of Hodgkin's lymphoma in adolescents

The aim was to assess outcome in a population-based cohort of adolescents with Hodgkin's lymphoma (HL) diagnosed in the UK's northern region over a 10-year period. Among a population of 3.09 million, 55 of 676 patients (8%) diagnosed with HL were aged 13–19. Seven had nodular lymphocyte-predominant HL, 48 classical HL (cHL). Of the latter, 36 were ⩾16 years. Application of the Scottish and Newcastle Lymphoma Group (SNLG) prognostic index meant 21 patients were considered high risk (index ⩾0.5). They received PVACEBOP multi-agent chemotherapy as primary therapy. Standard risk patients (SNLG index <0.5) were treated with standard ChlVPP or ABVD chemotherapy±radiotherapy. Scottish and Newcastle Lymphoma Group indexing is not valid for patients under 16. Twelve patients therefore received UKCCSG protocols (n=8), ABVD plus radiotherapy (n=2), or PVACEBOP (n=2). Forty-six patients with cHL (96%) achieved complete remission. Seven patients relapsed but all entered complete remission after salvage therapy. Five patients died: three of HL, one in an accident and one of disseminated varicella complicating cystic fibrosis. Five- and 10-year overall survival was 93 and 86%, respectively; disease-specific survival was 95 and 92%. The data suggest that older adolescents with high-risk HL require intensive protocols as primary therapy to secure optimal outcome.